Tuesday, June 21, 2011

No doubt you’ve been aware of the latest survey on the topic of disruptive behavior in health care. The results of our joint study with QuantiaMD are the same as our ACPE survey nearly two years ago. We physicians still have a lot of work to do in our own house to solve this patient safety issue. We’re making progress. But it’s time to look at another angle of how physicians become labeled as “disruptive”. Sometimes the label is just plain wrong. Like old Hollywood westerns, or Patrick Swayze movies, the hero is often bullied by powerful people and organizations who feel that their authority is threatened, or who perceive that the status quo might change.

Since this latest study was published, I’ve had lots of interesting discussions with physicians, and senior health system leaders. Some senior leaders who come from non-health care industries comment on the odd culture of health care compared to many other industries. They point out (it’s also my experience) that disagreement, rather than being viewed as a strong cultural attribute for innovation and change, is frequently considered a threat to the hierarchy. Sometimes decision-making is highly centralized in the C-suite, and leaders are very uncomfortable with questions or differing opinions. In these health systems, the organizational Kool-Aid demands “loyalty” to the leaders, rather than legitimate, truthful debate about the merits of strategy, policies, or procedures. More about “loyalty” later!

When faced with a physician who voices distaste with the Kool-Aid of mindless agreement, these leaders label her/him “disruptive” – not because of behavior, but because of disagreement! That can lead to all sorts of problems for the physician who must then answer to the official organizational procedures for dealing with the disruptive physician, such as medical staff or legal proceedings.

In my first health system leadership job, I remember asking the senior physician leader of the system what Dr. X thought of the strategy proposed. “He disagrees with us, so we’ve removed him from the committee.”

Dr. X was a physician who was respected and admired by his peers, by the nurses, technicians, and support staff who dealt with him, and most importantly, loved and respected by his patients. At least he wasn’t officially labeled disruptive, and made to go through counseling or monitoring! His disagreement with the strategy was shown to be correct a few months later.

Another physician with the same excellent clinical and service reputation came to me looking for a job. He’d been fired from another system because he disagreed with administration, sometimes too aggressively and disrespectfully. After listening to my new management colleagues advise against hiring him, and sharing my obvious concerns with him about his behaviors around managers or executives, I hired him. His dedication to patients, and his remarkable creativity were the characteristics my physician group needed. Working with him to change his behavior when he became frustrated or angry, he gradually learned how to use more productive behaviors. He got his 5-year pin, and eventually was named physician of the year by a well known national health care organization.

Both of these physicians were labeled as cynics by those who didn’t appreciate their disagreement. The best definition of a cynic is “a passionate person who doesn’t want to be disappointed again.” (Benjamin Zander, conductor of Boston Philharmomic) I learned that disagreement, when respectful and done in the spirit of innovation and improvement, is good. It’s what I like about working with talented and passionate people. It should not be extinguished. It should be encouraged.

If you hear your senior leader ask for “loyalty” – watch out! It’s just another way to stifle honest disagreement, or can be viewed as bullying.

I’ve never forgotten what I was told by a senior legal counsel in one of my first health care jobs, “Sometimes loyalty is more important than telling the truth.” Not for me.

You can hear the word “loyalty” used when uncomfortable decisions are made without the input of experts, when leaders don’t want to be questioned, or in a complex situation with public relations implications is unfolding. I don’t believe that a leader should ask for loyalty from followers. Loyalty can only be given freely by those who choose to follow, not forced upon them by a leader. Maybe if you run a monarchy or dictatorship it’s OK to ask for loyalty.

This quote from Col. John Boyd helps me put the issue of loyalty in proper perspective:

“If your boss demands loyalty, give him integrity. But if he demands integrity, give him loyalty.”